SOP_NUMBER: 508.43
TITLE: Tele-Mental Health Services
DIVISION: Health Services Division (Mental Health)
TOPIC_AREA: 508 Policy-MH Evaluations/Screenings/Treatment
EFFECTIVE_DATE: 2018-09-25
WORD_COUNT: 1396
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/433887
URL: https://gps.press/sop-data/508.43/
SUMMARY:
This policy establishes standards for Georgia Department of Corrections mental health professionals to deliver mental health services to incarcerated individuals using telecommunication technologies. The policy applies to all clinical staff providing tele-mental health services and requires compliance with HIPAA standards, applicable professional licensing requirements, and established guidelines from national mental health organizations. Key requirements include ensuring care quality is equivalent to in-person services, obtaining offender consent, requiring in-person visits for psychiatry services every six months, and maintaining confidentiality of all transmitted records.
KEY_TOPICS: tele-mental health, telehealth mental health, remote mental health services, videoconferencing, mental health evaluation, psychiatry services, electronic communication, HIPAA compliance, telepсychiatry, video teleconference, mental health treatment at distance, clinical supervision, offender mental health care, correctional mental health
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|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Tele-Mental Health Services|**Policy Name:**Tele-Mental Health Services|**Policy Name:**Tele-Mental Health Services|
|**Policy Number:** 508.43|**Effective Date:** 9/25/2018|**Page Number:** 1 of 6|
|**Authority:**
Commissioner
|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level I: All Access
|
**I.** **Introduction and Summary:**
Tele-mental health is used by mental health professionals to provide services at a
distance via telecommunication technologies in accordance with applicable
standards. The telecommunication system used will meet all Health Insurance
Portability and Accountability Act (HIPAA) requirements.
**II.** **Authority:**
A. GDC SOPs: 508.07 Clinical Supervision, 508.09 MH/MR Records, 508.10
Confidentiality of Mental Health Records, 508.24 Psychotropic Medication Use
Management, 508.15 Mental Health Evaluations, 508.19 Mental Health Referral
and Triage, 508.26 Involuntary Medication Administration, 208.02 Telemedicine
- Facilities, 507.04.12 Telemedicine - Physical Health, 508.30 Mental Health
Acute Care Unit; 508.31 Mental Health Crisis Stabilization Unit, 508.22 Mental
Health Management of Suspected Sexual Abuse or Sexual Harassment, and
508.37 Suicide Prevention and Management of the Potentially Suicidal Offender;
B. American Psychological Association Guidelines for Practice of Telepsychology;
C. American Psychiatric Association Telepsychiatry Guidelines;
D. American Telemedicine Association Practice Guidelines for Videoconferencing
Based Tele-Mental Health; and
E. ACA Standard: 4403-1.
**III.** **Definitions:**
A. **Tele-mental Health** - The use of electronic communication and information
technologies to provide or support mental health care from a remote location.
B. **Remote Services** - Services that are received from a different site than where the
clinician is physically located. The term “remote” includes no consideration in
relation to distance, but rather, may refer to a site that is in the same building or
at great distance from the clinician.
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Tele-Mental Health Services|**Policy Name:**Tele-Mental Health Services|**Policy Name:**Tele-Mental Health Services|
|**Policy Number:** 508.43|**Effective Date:** 9/25/2018|**Page Number:** 2 of 6|
|**Authority:**
Commissioner
|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level I: All Access
|
C. **In-Person Services** - Interactions in which the clinician and the offender are in
the same physical space and do not include interactions that may occur through
the use of technologies.
D. **Shadow** **File** - A secure electronic or paper file containing key elements of the
offender’s medical record. This file is used as a reference by the health
professional providing care during each tele-mental health session.
E. **Videoconferencing Service** - Any third-party/intermediary service hosting a
tele-mental health audio and video session. This includes a service initiating a
session between two peer computers, or an intermediary service to which all
parties connect for transmission and reception of audio and video.
F. **Electronic Transmission** - Any method of electronic data transfer. This
includes (but is not limited to) facsimile, email, FTP (File Transfer Protocol),
SFTP (Secure File Transfer Protocol), SCP/SSH (Secure Copy/Secure Shell), or
SMB (Server Message Block).
G. **Tele-mental Health Site Coordinator** - A staff member identified to manage
the tele-mental health process, from coordinating schedules; managing the
transmission of medical records; and telecommunication troubleshooting. This
staff member works in collaboration with the clinical coordinator on site.
**IV.** **Statement of Policy and Applicable Procedures:**
A. Clinical staff using these services ensure that the standard of care delivered via
tele-mental health is at least equivalent to the quality of any other type of care
that can be delivered to the offender, considering specific context, location,
timing and access to care.
1. Clinical staff providing tele-mental health services must be fully licensed in
their discipline and utilize the practice guidelines consistent with their
professional discipline to guide the delivery of care;
2. Where there is not a licensed, qualified staff member available on-site to
provide in person services, the offender should be transported for a face-to
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Tele-Mental Health Services|**Policy Name:**Tele-Mental Health Services|**Policy Name:**Tele-Mental Health Services|
|**Policy Number:** 508.43|**Effective Date:** 9/25/2018|**Page Number:** 3 of 6|
|**Authority:**
Commissioner
|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level I: All Access
|
face evaluation or arrangements should be made for tele-mental health
services at a facility that has a licensed, qualified staff member;
3. Any modifications to clinical practice standards for the tele-mental health
ensure that clinical requirements specific to professional discipline are
maintained;
4. Clinical staff performing tele-mental health services are provided
training/orientation and receive ongoing continuing education to maintain
identified skills and ethical standards to provide or support tele-mental health
services;
5. All credentialing requirements for staff providing face-to-face services apply
to staff providing tele-mental health services;
6. Licensed clinical staff providing tele-mental health services shall be licensed
in the state where the clinician is located as well as where the offender is
located;
7. If a facility primarily utilizes tele-mental health for psychiatry services, the
provider must provide in-person psychiatry services every six (6) months to:
a. Meet staff;
b. Communicate with offenders;
c. Participate in the treatment team meeting(s); and
d. Observe conditions of confinement, etc.
8. Although there are no absolute exclusionary criteria for the use of tele-mental
health, the following represent situations when the clinical staff and on-site
staff may determine the use is contraindicated for a particular offender:
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Tele-Mental Health Services|**Policy Name:**Tele-Mental Health Services|**Policy Name:**Tele-Mental Health Services|
|**Policy Number:** 508.43|**Effective Date:** 9/25/2018|**Page Number:** 4 of 6|
|**Authority:**
Commissioner
|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level I: All Access
|
a. Refusal to participate;
b. Immediate risk of dangerousness except for triage purposes;
c. Presence of psychiatric symptoms that could be exacerbated by the use of
telecommunication technology (auditory hallucinations, extreme
paranoia, specific delusions regarding technology);
d. Hearing, visual, or cognitive deficits that might limit the offender’s
ability to communicate with tele-mental health;
e. Evaluation of victims of alleged sexual assault except for triage purposes;
and
f. Higher levels of care (Levels III - VI) should only receive tele-mental
health services as a temporary measure if there is an in-person vacancy.
9. At the start of a tele-mental health session, the provider will educate the
offender about the nature of tele-mental health and obtain verbal consent for
tele-mental health services;
10. All persons present at the receiving and providing sites should be made
known to the provider and offender during each session;
11. Nurses and other mental health staff should not remain in the room during the
tele-mental health session, except to answer questions or provide needed
information;
12. The following information will be made available to the provider prior to the
tele-mental health clinic:
a. List of offenders who will be seen (to include, GDC#, location, mental
health level);
b. Current Medication Administration Record (MAR); and
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Tele-Mental Health Services|**Policy Name:**Tele-Mental Health Services|**Policy Name:**Tele-Mental Health Services|
|**Policy Number:** 508.43|**Effective Date:** 9/25/2018|**Page Number:** 5 of 6|
|**Authority:**
Commissioner
|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level I: All Access
|
c. Shadow file containing the most recent Progress Notes, Labs, Initial
Psychiatric/Psychological Evaluation, Transfer Evaluation, Diagnosis
List, Abnormal Involuntary Movement Scale (AIMS), weight and waist
measurements, and Informed Consents.
13. Receipt of the above information may be through fax, shadow file, or
electronic record. It is the responsibility of the provider to request the
information if it is not available. Verbal report may be given if the
information is not available through other mechanisms;
14. All documentation requirements for face-to-face sessions apply to tele-mental
health sessions;
15. All medication orders shall be faxed to the offender’s facility by close of
business on the day of the session;
16. All aspects of HIPAA and state privacy requirements apply to the tele-mental
health session and the transmission of medical information;
17. Any tele-conferencing system utilized will be HIPAA compliant;
18. Quality of video transmission is maintained at sufficient resolution to deliver
clinical services; and
19. Continuous Quality Improvement (CQI) data is maintained to include but not
limited to:
a. Information concerning the number of offenders seen by tele-mental
health;
b. The numbers of no-shows;
c. The numbers of day evaluations;
d. Offender satisfaction; and
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Tele-Mental Health Services|**Policy Name:**Tele-Mental Health Services|**Policy Name:**Tele-Mental Health Services|
|**Policy Number:** 508.43|**Effective Date:** 9/25/2018|**Page Number:** 6 of 6|
|**Authority:**
Commissioner
|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level I: All Access
|
e. Other related measures of offender outcomes.
**V.** **Attachments:** None.
**VI.** **Record Retention of Forms Relevant to this Policy:** None.